Originally shared in the Jan/Feb 2021 PPMA Newsletter

Answers provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: What CPT code should I use for initial nursing home
encounters? Can podiatrists use CPT 99304?


A: CPT codes 99304–99306 describe initial nursing facility care. Yes,
podiatrists can absolutely submit initial nursing facility evaluation and
management (E/M) codes for Medicare patients.

Medicare does not recognize consultation codes. When Medicare stopped
recognizing consultation codes on January 1, 2010, it then instructed specialists,
including podiatrists, to use the initial nursing facility CPT codes when
seeing a nursing facility patient for the first time during that patient’s
admission.

Podiatrists should use initial nursing facility codes for Medicare patients if
that encounter qualified for what the facility would consider a “consult,” even
if the specialist was not the admitting/primary doctor. Since there are now
multiple doctors using those initial encounter codes, the admitting/primary
doctor must use an “AI” modifier on the initial E/M encounter.

This change did not alter the fact that in order to submit any E/M code, one
must meet the thresholds of complexity for that code. Complexity refers to
the key elements of E/M coding (history, exam, decision-making) in what
you performed; what you documented; and what was medically necessary for
that level. If counseling and coordinating dominate the visit, time may be
used to select the appropriate level.

These thresholds and time requirements are relatively high for the lowest
level initial nursing facility E/M (CPT 99304). Therefore, CMS clarified that
it is appropriate for specialists to use the subsequent nursing facility E/M
codes for initial encounters that do not meet the complexity thresholds for
CPT 99304. This is an important point. Even though podiatrists can use
initial nursing facility E/M codes for Medicare patients, every initial encounter
does not automatically qualify for the use of an initial encounter E/M.
For Non-Medicare payers that still recognize consultation codes, podiatrists
should still use consultation codes for nursing home consults.